Provider Demographics
NPI:1407164353
Name:CLARK, JILL M (DC)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 W OHIO ST # 3F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-7436
Mailing Address - Country:US
Mailing Address - Phone:563-370-7626
Mailing Address - Fax:
Practice Address - Street 1:401 W ONTARIO ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-6957
Practice Address - Country:US
Practice Address - Phone:312-943-3484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011762111N00000X
IA007265111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor